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RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTM [ NP T8 2016 <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGLF 1MENTAL 4� FALTH <br /> CLOSURE PERMIT KPARTMEVT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE , DO NOT WRITE IN ANY SHADED AREAS , INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT Will Namnath PHONE# 707-812- 1426 <br /> FACILITY NAME Spaulding Trust Property IPHONE # <br /> ADDRESS 540 North EI Dorado Street, Stockton , CA 95203 <br /> CROSS STREET Oak Street <br /> OWNER OPERATOR Spaulding Trust Property PHONE # <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Advanced GeoEnvironmental , Inc. - William Little PHONE # 209 467 1006 <br /> CONTRACTOR ADDRESS 837 Shaw Road, Stockton , CA 95215 CA LIC # 680 227 CLASS A - Haz <br /> INSURER Travellers WORKER COMP# UB3338T982 <br /> FIRE DISTRICT Stockton PERMIT # <br /> LABORATORY NAME Precsion Enviro-Tech COUNTY San Joaquin PHONE # (209) 477-8105 <br /> SAMPLING FIRM Pression Enviro-Tech PHONE # 209 477-8105 <br /> TANK INFORMATION <br /> TANK ID # TANK SI7_E TANK CONTENTS (PRESENT AND PAST) DATE INSTALLED <br /> 39- 250-500 Fuel Undetermined <br /> 39- <br /> 39 - <br /> 39 - <br /> 39 - <br /> 39 - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS , FEDERAL LAWS , AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK. FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR 'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING : " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER 'S COMPENSATION LAWS OF CALIFORNIA." Q <br /> APPLICANT'S SIGNATURE - --:; Jif TITLE + � ��_ DATE <br /> ❑ APPROVED PPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> ( EE C ITIO NDJS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER 'S NA tOM <br /> L�` ` DATE O <br /> ANY DEVIATIONS THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WO K . <br /> CONDITIONS : <br /> EI-1 23 046 ( Revised 7/26/2016 ) 3 <br />